Provider Demographics
NPI:1437194990
Name:FAGGIONATO, TIMOTHY J (PA-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:FAGGIONATO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3260 PROVIDENCE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4615
Mailing Address - Country:US
Mailing Address - Phone:907-563-3145
Mailing Address - Fax:907-561-3967
Practice Address - Street 1:3260 PROVIDENCE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4615
Practice Address - Country:US
Practice Address - Phone:907-563-3145
Practice Address - Fax:907-561-3967
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK444363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S67658Medicare UPIN
AK160136Medicare PIN